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Differential Diagnosis Pediatric Limp

Complete the table. CC limp
Condition Age Pain (+ or -) Historical Findings Clinical Findings Causative Factors Management
Developmental Dysplasia of Hip
Leg-length Inequality
Juvenile Arthritis
Slipped capital femoral epiphysis (SCFE)
Legg-Calve-Perthes disease
Transient synovitis
Trauma
Neoplasm
Septic arthritis
Acute hematogenous osteomyelitis

Table 2
Differential Diagnosis Pediatric Headaches

Complete the table.
Common Types Diagnostic Criteria Based on History Treatment/Management
Pediatric Migraine Headache
Tension Headache
Chronic Tension Headache
Other Differentials: List 3 additional differentials for headache Characteristics Management

Complete the table.
Adolescent Idiopathic Scoliosis Osgood-Schlatter Disease Meniscal Tear Quadriceps Contusion Sprain of MCL Osteochondritis dissecans
Description
Screening Test?
How do you perform the screening test?
Imaging?
Treatment Plan

Case Scenario 1: Brenda is a 13-year-old brought into the clinic by her mother for a left leg limp she developed last week. Brenda’s BMI is >95%. She reports no history of injury and her past medical history is unremarkable. She can bear weight on her left leg but complains of left hip, groin, and knee pain when she does.
• What more should you know about Brenda?
• What specific exam techniques should you perform and why?
• What diagnostic tests should you order and why?

Full Answer Section

Slipped Capital Femoral Epiphysis (SCFE)	Adolescents (10-16 yrs)	+	Gradual onset hip/groin/thigh/knee pain, often obese, limp, decreased hip internal rotation	Limp, externally rotated leg, limited hip internal rotation and abduction	Mechanical stress on the growth plate of the femur	Non-weight bearing, urgent surgical stabilization (pinning)
Legg-Calve-Perthes Disease	Children (4-10 yrs)	+	Insidious onset hip/groin/thigh/knee pain, limp, activity-related pain	Limited hip abduction and internal rotation, muscle atrophy around hip	Idiopathic avascular necrosis of the femoral head	Containment of the femoral head within the acetabulum (bracing, surgery)
Transient Synovitis	Children (3-10 yrs)	+	Sudden onset hip/groin/thigh/knee pain, often after viral illness, refuses to bear weight	Limp, hip held in flexion, abduction, and external rotation, limited ROM	Inflammation of the hip joint lining (idiopathic, possibly post-viral)	Rest, NSAIDs, observation; symptoms usually resolve within a week
Trauma	Any	+	History of specific injury (fall, twist, direct blow)	Bruising, swelling, deformity, point tenderness, inability to bear weight	Direct force, twisting injury	Rest, ice, compression, elevation (RICE), immobilization, fracture care
Neoplasm	Any	+ (often progressive)	Persistent bone pain (worse at night), fatigue, weight loss, swelling, decreased function	Localized bone tenderness, swelling, palpable mass, systemic signs	Primary bone tumor (osteosarcoma, Ewing sarcoma), metastasis	Biopsy, chemotherapy, radiation therapy, surgery
Septic Arthritis	Any	+ (severe)	Fever, chills, refusal to move the limb, irritability	Warm, swollen, erythematous, exquisitely tender joint, limited ROM, fever	Bacterial infection of the joint space	Urgent joint aspiration and drainage, intravenous antibiotics
Acute Hematogenous Osteomyelitis	Any	+ (severe)	Fever, chills, localized bone pain, refusal to bear weight, irritability	Localized bone tenderness, swelling, warmth, limited ROM, fever, possible pseudoparalysis	Bacterial infection of the bone	Intravenous antibiotics, possible surgical drainage

Table 2: Differential Diagnosis Pediatric Headaches

Common Types	Diagnostic Criteria Based on History	Treatment/Management
Pediatric Migraine Headache	Recurrent headaches lasting 2-72 hours, at least two of: unilateral location, pulsating quality, moderate or severe pain intensity, aggravated by routine physical activity; during headache, at least one of: nausea/vomiting, photophobia, phonophobia; aura may be present.	Acute treatment: Pain relievers (ibuprofen, acetaminophen), triptans (age-dependent). Preventive treatment: Lifestyle modifications, medications (propranolol, topiramate, amitriptyline), CGRP inhibitors (age-dependent).
Tension Headache	Headache lasting 30 minutes to 7 days, at least two of: pressing/tightening (non-pulsating) quality, mild to moderate intensity, bilateral location, not aggravated by routine physical activity; both of: no nausea or vomiting, no more than one of photophobia or phonophobia.¹	Acute treatment: Pain relievers (ibuprofen, acetaminophen). Preventive treatment: Stress management, relaxation techniques, occasionally tricyclic antidepressants.
Chronic Tension Headache	Headache occurring on ≥ 15 days per month for > 3 months, typically with features of tension headache.	Similar to tension headache, but often requires a more comprehensive and long-term approach including behavioral therapies, physical therapy, and medication.
Other Differentials:	Characteristics	Management
1. Sinusitis Headache	Pain and pressure in the face, nasal congestion, purulent nasal discharge, fever.	Antibiotics if bacterial infection, decongestants, pain relievers.
2. Post-traumatic Headache	Headache that develops within 7 days of head injury or after regaining consciousness, may have features of migraine or tension headache.	Symptomatic treatment with pain relievers, management of associated symptoms (dizziness, irritability).
3. Meningitis Headache	Severe headache, stiff neck, fever, photophobia, altered mental status, nausea/vomiting.	Urgent medical evaluation and treatment with intravenous antibiotics and supportive care.

1. staging.brainscape.com

staging.brainscape.com

Table 3: Musculoskeletal Disorders and Sports-Related Injuries

	Adolescent Idiopathic Scoliosis	Osgood-Schlatter Disease	Meniscal Tear	Quadriceps Contusion	Sprain of MCL	Osteochondritis Dissecans
Description	Lateral curvature of the spine with rotation, onset in adolescence	Painful bump below the kneecap at the tibial tuberosity	Tear in one of the cartilaginous menisci in the knee	Bruising and pain in the thigh due to direct impact	Pain and instability on the inner side of the knee	Fragment of cartilage and underlying bone separates from joint surface
Screening Test?	Adam's Forward Bend Test	Palpation of the tibial tuberosity for tenderness and swelling	McMurray Test, Thessaly Test, Apley Grind Test	Observation for swelling and bruising, palpation for pain	Valgus stress test	Wilson's Test (for knee)
How do you perform the screening test?	Patient bends forward at the waist with arms hanging down; observe for asymmetry in rib height or trunk shift.	Palpate the tibial tuberosity while the knee is extended and flexed.	Perform specific maneuvers involving knee flexion, extension, and rotation to elicit pain or clicking.	Palpate the quadriceps muscle group for tenderness and swelling while assessing range of motion.	Apply gentle outward force to the knee with the leg slightly bent to assess for laxity and pain.	Passively extend the knee while internally rotating the tibia; pain at a specific angle suggests OCD.
Imaging?	Standing full spine X-rays (AP and lateral)	Usually clinical diagnosis; X-rays may show fragmentation	MRI is the gold standard	X-rays to rule out fracture	X-rays to rule out fracture; MRI may show ligament damage	X-rays may show lesion; MRI can define cartilage involvement
Treatment Plan	Observation, bracing (for moderate curves), surgery (for severe)	Rest, ice, NSAIDs, activity modification, stretching	Conservative (PT) for small tears, surgery for significant tears	Rest, ice, compression, elevation (RICE), gradual return to activity	RICE, bracing, physical therapy for strengthening	Activity modification, immobilization, possible surgical fixation or removal

What more should you know about Brenda?
- Onset and Progression: Was the limp sudden or gradual? Has the pain worsened, stayed the same, or improved?
- Pain Characteristics: Can she describe the pain (sharp, dull, aching)? What makes it better or worse? Does it radiate?
- Activity Level: What are her usual activities? Has she been participating in any new or strenuous activities recently?
- Associated Symptoms: Any fever, chills, night sweats, weight loss, rash, or other joint pain?
- Gait: How is she walking? Is she favoring the left leg significantly?
- Family History: Any family history of hip problems, arthritis, or other musculoskeletal conditions?
- Recent Illness: Any recent viral infections or illnesses?
What specific exam techniques should you perform and why?
- Gait Observation: Observe her walking to assess the limp pattern and weight-bearing ability.
- Palpation: Palpate the hip, groin, thigh, and knee for tenderness, swelling, and warmth.
- Range of Motion (ROM): Assess the active and passive range of motion of her left hip, knee, and ankle, noting any limitations or pain with movement, specifically internal and external rotation of the hip.
- Log Roll Test: With Brenda supine, passively roll her leg internally and externally to assess for pain within the hip joint.
- FABER (Flexion, Abduction, External Rotation) Test (Patrick's Test): Place the lateral malleolus of one leg on the opposite knee and gently lower the flexed knee towards the examining table to assess for hip or sacroiliac joint pain.
- Galeazzi Sign/Allis Test: With Brenda supine and knees bent and feet flat on the table, assess if the knees are at the same height to screen for leg length discrepancy (relevant for DDH or SCFE).
- Trendelenburg Test: Observe her standing on one leg at a time to assess for hip abductor weakness.
- Neurovascular Exam: Assess distal pulses, capillary refill, and sensation in the left leg to rule out neurovascular compromise.
What diagnostic tests should you order and why?
- Bilateral Hip and Pelvis X-rays (AP and Frog-leg Lateral): Given her age, pain pattern (hip, groin, knee), limp, and obesity, Slipped Capital Femoral Epiphysis (SCFE) is a strong concern. Frog-leg lateral view is crucial for detecting subtle slips. X-rays can also help rule out other bony abnormalities or Legg-Calve-Perthes disease.
- Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): To evaluate for inflammatory conditions like transient synovitis or septic arthritis. Elevated inflammatory markers would raise suspicion for infection or inflammatory arthropathy.
- Complete Blood Count (CBC) with Differential: To assess for signs of infection (elevated white blood cell count).
- Consider Ultrasound of the Hip: If SCFE is not immediately apparent on X-ray but suspicion remains high, or to evaluate for joint effusion suggestive of transient synovitis or septic arthritis (though aspiration would be needed to confirm infection).
- Consider MRI of the Hip: If X-rays are inconclusive and there is persistent pain and limp, MRI can provide more detailed imaging of the soft tissues and bone, helping to diagnose early SCFE, Legg-Calve-Perthes disease, or other less common conditions.

The combination of Brenda's age, obesity, insidious onset of hip/groin/knee pain, and limp strongly suggests the need to rule out SCFE urgently.

Sample Answer

Table 1: Differential Diagnosis of Pediatric Limp

Condition	Age	Pain (+ or -)	Historical Findings	Clinical Findings	Causative Factors	Management
Developmental Dysplasia of Hip (DDH)	Infants/Toddlers	- (often painless in infants)	Breech presentation, family history of DDH, click/clunk on infant exam (if undiagnosed)	Limited hip abduction, Galeazzi sign (uneven knee height), asymmetric thigh folds	Genetic predisposition, intrauterine positioning	Pavlik harness (infants), closed or open reduction with spica cast (older)
Leg-length Inequality	Any	+/-	Observation by parents, uneven wear on shoes	Visible difference in leg length, scoliosis (compensatory)	Congenital, growth disturbance, injury	Shoe lifts, observation, surgical equalization in severe cases
Juvenile Arthritis (JIA)	Any (peak 1-3 yrs, 8-12 yrs)	+	Joint pain, stiffness (especially in the morning), swelling, fever, rash, eye involvement	Joint swelling, warmth, tenderness, limited range of motion, systemic signs	Autoimmune diso